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SA, JOAQUIN LL1LAL�HLALfH Ulb [RlLl <br /> FOR OFFICE USE: 1601 E. elton' Ave. , Stockton, CA 95', Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> r Complete In Triplicate) <br /> application is hereby made to�the%San Joaquin Local Health District for a permit to construct <br /> nd/or install the work hergin degcribed. This application is made in compliance with San <br />•oanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> listrict. <br /> XACT STREET ADDRESS CITY/TOWN /� � <br /> owner's Name Phone `O <br />.ddress / ` City <br /> ontractor's NameAl icenseje�1 Phone <br /> S CERTIFICATE OF WORKMAN'S COdANSATION INSURAINCE VFI'LE WITH SJLHD? YES NO <br /> YPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WE(.L CHLORINATION ❑ WELL ABANDONMENT O OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> ISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELD CESSP>POOL/SEEPAGE PIT OTHER O <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We Exp cavation <br /> c/Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing /2- 4 A-- <br /> Irrigation "w Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal t • :Other Other Information <br /> Geophysical Surface Seal Insta e by: zzcl <br /> 1MP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> JMP REPLACEMENT: [] State Work' Done <br /> yMP REPAIR: Q State Work Done' <br />,STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordance <br /> th San Joaquin County. Ordinances, State Laws, and Rules and Regulations of the San Joaquin Locall <br /> alth District. Home owner.,or. licensed agent's signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall <br /> not a any p�Son <br /> such manner as to become subject to Workman's Compensation <br /> 1 of Cal orn <br /> W� L CALL F A G CT IO TO GROUTING ANQA <br /> FINAL INSPECTION. <br /> 16NED ,�. �( TITLE: X6) i DATE: <br /> (DRAW.PLOT PLAN ON REVERSE IDE <br /> DE R MENT "USE ONLY <br /> 4SE I �/. I <br />— LICATION ACCEPTED BY DATE�-2/ % <br /> )ITIONAL COMMENTS: <br /> PHASE II GROUT IfISPECTION PHASE III SINAL INSPECTION <br /> ;PECTION BY _ DATE /— INSPECTION BY , Rte — DATE,57—,77-;1S <br /> tA7f !._ 1n 7l �n n <br />